Brain Neurorehabil.

2022 Nov;15(3):e25
https://doi.org/10.12786/bn.2022.15.e25
pISSN 1976-8753·eISSN 2383-9910 Brain & NeuroRehabilitation

Focused Review
Diagnosis, Treatment, and
Brain Tumor Rehabilitation:
Rehabilitation for Adult Symptoms, Complications, and
Glioma
Treatment Strategy

Jinyoung Park, Yoon Ghil Park

Received: Oct 18, 2022

Accepted: Nov 15, 2022
HIGHLIGHTS
Published online: Nov 29, 2022
• Patients with brain tumors experience weakness, cognitive and emotional dysfunction.
Correspondence to • Seizures, headaches, and dysphagia are common complication of brain tumors.
Yoon Ghil Park • Multidisciplinary assessment is necessary to treat tumor-related impairment.
Department of Rehabilitation Medicine,
Gangnam Severance Hospital, Yonsei
University College of Medicine, 211 Eonju-ro,
Gangnam-gu, Seoul 06273, Korea.
Email: DRTLC@yuhs.ac

Copyright © 2022. Korean Society for Neurorehabilitation i

Brain Neurorehabil. 2022 Nov;15(3):e25
https://doi.org/10.12786/bn.2022.15.e25
pISSN 1976-8753·eISSN 2383-9910 Brain & NeuroRehabilitation

Focused Review
Diagnosis, Treatment, and
Brain Tumor Rehabilitation:
Rehabilitation for Adult Symptoms, Complications, and
Glioma
Treatment Strategy

Jinyoung Park , Yoon Ghil Park

Department of Rehabilitation Medicine, Gangnam Severance Hospital, Yonsei University College of

Medicine, Seoul, Korea

Received: Oct 18, 2022

Accepted: Nov 15, 2022
ABSTRACT
Published online: Nov 29, 2022
Brain tumors are receiving increasing attention in cancer rehabilitation due to their high rate
Correspondence to of neurological deterioration. Motor dysfunction, cognitive deterioration, and emotional
Yoon Ghil Park
problems are commonly present in patients with brain tumors. Other medical complications,
Department of Rehabilitation Medicine,
Gangnam Severance Hospital, Yonsei
such as seizures, headache, and dysphagia are also common. An individualized
University College of Medicine, 211 Eonju-ro, multidisciplinary rehabilitation intervention is necessary to treat functional impairment due
Gangnam-gu, Seoul 06273, Korea. to the tumor itself and/or treatment-related dysfunction. Herein, we discuss rehabilitation
Email: DRTLC@yuhs.ac treatment strategies in relation to the neurological and functional complications that
commonly occur in patients with brain tumors.
Copyright © 2022. Korean Society for
Neurorehabilitation
Keywords: Brain Tumor; Cognitive Dysfunction; Fatigue; Rehabilitation; Weakness
This is an Open Access article distributed
under the terms of the Creative Commons
Attribution Non-Commercial License (https://
creativecommons.org/licenses/by-nc/4.0)
which permits unrestricted non-commercial
INTRODUCTION
use, distribution, and reproduction in any
medium, provided the original work is properly Despite making up a small proportion of all cancers, brain tumors are receiving increasing
cited. attention in cancer rehabilitation due to their high rate of neurological deterioration. The
degree and type of impairment may depend on the tumor pathology and the lesion site. The
ORCID iDs
Jinyoung Park
majority of brain tumors have poor survivorship and prognoses, and benign tumors might be
https://orcid.org/0000-0003-4042-9779 challenging to treat completely and are likely to recur.
Yoon Ghil Park
https://orcid.org/0000-0001-9054-5300 The neurological complications commonly reported in patients with brain tumors in
the early rehabilitation setting include cognitive dysfunction (80%), motor dysfunction
Funding
None. (78%), visuoperceptual deterioration (53%), sensory problems (38%), and bowel/bladder
dysfunction (37%). Three or more impairments were observed in 75% of patients, and five or
Conflict of Interest more impairments in 39% of patients [1].
The authors have no potential conflicts of
interest to disclose.
A rehabilitation intervention is required for more than 80% of patients with central nervous
system tumors [2]. However, it can be difficult to communicate with patients and families
about brain tumors in a rehabilitation setting because most initial inquiries concern the
primary prognostic and treatment considerations for tumors, which are typically the purview
of neurosurgery, medical oncology, and/or radiation oncology.

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Table 1. Common neurological and physical complications of brain tumors

Neurological complications Other medical complications
Cognitive dysfunction Hemodynamic/vascular complications
Memory disorder Hypertension
Communication difficulties Arterial thrombotic events
Mood disorder Venous thromboembolism
Depressive disorder Pulmonary embolism
Anxiety disorder Vasogenic edema
Impulse control disorder Endocrinopathies
Personality disorder Decreased production: GH, TSH, ACTH, gonadotropins
Seizure Amenorrhea
Pain Infections
Headache Pneumonia
Other neuropathic pain Urinary infections
Motor dysfunction
Weakness
Spasticity
Dyskinesia
Dystonia
Fatigue
Sensory deterioration
Sensory impairment
Proprioception impairment
Visual disturbance
Auditory dysfunction
Dysarthria
Dysphagia
Aphasia
Neurogenic bladder/bowel
Sexual dysfunction
GH, growth hormone; TSH, thyroid stimulating hormones; ACTH, adrenocorticotropic hormones.

An individualized multidisciplinary rehabilitation intervention is necessary to treat

functional impairment due to the tumor itself and/or treatment-related dysfunction. Herein,
we discuss rehabilitation treatment strategies in relation to the neurological and functional
complications that commonly occur in patients with brain tumors (Table 1).

PHYSICAL PROBLEMS
Motor dysfunction
Motor dysfunction in patients with primary brain tumors can occur due to a variety of
causes, including as a direct effect of the tumor’s location or swelling or as a side effect of
neurosurgery, chemotherapy, radiation, steroids, or other drugs [3]. Myopathy was reported
in 10% of patients with brain tumors who received dexamethasone for more than 2 weeks,
and approximately two-thirds of these myopathic patients developed symptoms after
continuous administration of dexamethasone for 9–12 weeks [4].

Rehabilitation interventions focus on preventing or improving motor dysfunction, and thus

preserving or enhancing quality of life [3]. The daily functional improvements made by patients
with brain tumors receiving inpatient hospital-based rehabilitation could be comparable to
those made by stroke and traumatic brain injury patients [5,6]. A systematic review suggested
that exercise is safe and feasible in patients with brain tumors, yielding some benefits in terms
of symptom severity and interference. Although the level of evidence is still low, exercise has
been shown to improve aerobic capacity, body composition, and levels of physical activity [7].

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Brain Tumor Rehabilitation Brain & NeuroRehabilitation

Fatigue
Fatigue is commonly present in patients with brain tumors, and its incidence increases with
treatment, such as chemotherapy, radiation therapy, and the use of anticonvulsant drugs [8].
The lifelong prevalence of fatigue has been reported in up to 70% of patients [9,10].

Fatigue care can be approached both non-pharmacologically and pharmacologically. As

non-pharmacologic treatments, several strategies have been revealed to be effective, such
as physical exercise, behavioral management, coping strategies, dietary modifications
including adequate hydration, and the management of anemia [8]. Pharmacologically,
psychostimulants such as methylphenidate, modafinil, and armodafinil have not
demonstrated significant benefits in randomized trials, but may be effective in managing
fatigue [9,11,12].

COGNITIVE AND EMOTIONAL PROBLEMS

Cognitive dysfunction
Cognitive dysfunction and attentional deterioration commonly accompany brain tumors
and can interfere with rehabilitation plans. Brain tumors in the frontal or temporal lobe
can deteriorate attention, lower executive ability, and/or decrease the speed of information
processing. These deteriorations may be exacerbated or prominently manifested by
chemotherapy and radiation therapy [4]. Cognitive changes after chemotherapy are primarily
associated with the effects of high levels of cytokines, DNA damage, and neurotoxic damage of
brain white matter. Fatigue, depression, and psychosomatic effects can also play a secondary
role in cognitive dysfunction [13]. It has been reported that 50% to 90% of brain tumor patients
who survived for more than 6 months after radiation therapy have radiation-induced cognitive
dysfunction [14]. Radiation-induced encephalopathy can occur in the acute or late phase and is
related to injuries of neural cells themselves or vascular endothelial cells [14].

Meyers and colleagues found methylphenidate to be effective in improving cognitive

function, including memory, expressive speech function, and executive function in patients
with brain tumors [15]. Other agents that have been studied to enhance cognitive function
include donepezil, modafinil, hyperbaric oxygen, and bevacizumab [16]. Neuropsychological
rehabilitation interventions should be incorporated into the treatment plan, according to
Janda and her colleagues, who analyzed the unmet needs of patients and caregivers with brain
tumors for supportive care [17]. A randomized clinical study by Gehring and colleagues found
that patients who participated in a cognitive rehabilitation program including executive
function, memory, and attention compensatory skills training, as well as computer-based
attention retraining, performed better on neuropsychological tests, had better attention and
memory, and experienced less psychological fatigue [18].

Mood disorders
When a brain tumor is detected, up to 42% of patients have major depressive disorder, which
can deteriorate over time [19]. Depression is related to cognitive dysfunction and functional
impairment, which reduce the quality of life.

Antidepressants have been shown to be safe, without unsafe drug interactions with other
chemotherapeutic agents. However, medications known to lower the seizure threshold, such
as bupropion and clomipramine, should be avoided [4,20]. Limited data exist regarding the

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Brain Tumor Rehabilitation Brain & NeuroRehabilitation

efficacy of psychosocial interventions combined with other treatments, such as cognitive

and/or physical therapies [21].

OTHER COMPLICATIONS
Seizures
Seizures commonly occur in patients with brain tumors, being reported in 20%–40% of
patients with high-grade tumors, 50%–85% of those with low-grade tumors, and 15%–20%
of those with brain metastasis [3,22]. It is crucial to treat a number of triggering factors,
including tumor growth, brain edema, intracranial pressure, metabolic problems, and other
tumor-related factors, in order to achieve optimal seizure management [4].

Treatment for epilepsy often requires a lifetime commitment. However, antiepileptic drugs
(AEDs) can be discontinued in carefully selected patients who have been seizure-free for
a long time and have a low risk of tumor progression [23]. Adverse effects of AEDs should
prompt consideration of discontinuation. In several previous studies, the incidence of
adverse events brought on by prophylactic AEDs was rather significant, reaching 34%.
Significantly, serious side effects such as toxic epidermal necrolysis and lowered levels of
consciousness were documented [24-26]. A decreased level of consciousness can be a major
obstacle to rehabilitation treatment.

Prospective studies and a meta-analysis on seizure-free brain tumor patients have

not found seizure-prophylactic effects of AEDs [27-29]. More recently, the European
Association of Neuro-Oncology and Society for Neuro-Oncology practice guideline update
on anticonvulsant prophylaxis in brain tumors also warned against the use of preventive
anticonvulsants [30]. According to the guideline, in seizure-free individuals with newly
diagnosed brain tumors, AEDs should not be prescribed to reduce the risk of seizures (grade
of recommendation: A). In patients with brain tumors undergoing surgery, there is not
enough evidence to recommend the prescription of AEDs to reduce the risk of seizures in the
perioperative or postoperative period (grade of recommendation: C).

Headache
In 53% of patients with brain tumors, headaches have been reported; 77% of these patients
experience tension headaches, the most prevalent type of headache [7,31]. Local traction on
pain-sensitive tissues, such as the cranial nerves, venous sinuses, arteries, and sections of the
dura has been suggested as potential headache triggers.

Appropriate treatment is necessary because headache can act as a hindrance to rehabilitation

and reduce motivation. Corticosteroids (particularly when there is a rise in intracranial
pressure), surgical procedures, or radiation therapy can be used for the management of
headache. Typically, after a craniotomy, analgesics are needed.

Dysphagia
The lifelong prevalence of dysphagia in patients with brain tumors has been reported to be
as high as 85% [32]. When dysphagic patients with stroke and brain tumors were matched,
both had statistically similar incidence rates and patterns of dysphagia. In addition, there
was no significant difference in swallowing functions between patients with benign and

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Brain Tumor Rehabilitation Brain & NeuroRehabilitation

malignant brain tumors [33]. Dysphagia may be caused by focal neurological deficits, or
more commonly, deteriorated consciousness [34].

The inability to swallow affects nutrition, hydration, and medical therapy. No systematic
research has been done on the effects of hydration and tube feeding in patients with brain
tumors, but a study reported that swallowing function was improved in most patients with
supratentorial and infratentorial tumors by swallowing therapy and chemoradiotherapy [33].

CONCLUSION
Patients with brain tumors have a high rate of neurological impairment, resulting in functional
deficits. Individualized comprehensive rehabilitation management is necessary with treatments
that have been demonstrated to be beneficial, but some medical treatment and rehabilitation
interventions require more supporting evidence. What matters most is a multidisciplinary team
approach and frequent communication with patients and their families.

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